Itchy Skin Threatens CKD Patients' Quality of Life

More severe cases seen in those with higher stages of chronic kidney disease

MedpageToday

by Kristen Monaco, Staff Writer, MedPage Today
April 12, 2019

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Pruritus among non-dialysis chronic kidney disease (CKD) patients may be more common than previously realized, researchers reported.

In an international survey of 3,780 people with non-dialysis stages 3-5 CKD, 24% reported having moderate-to-extreme pruritus, Nidhi Sukul, MD, of the University of Michigan in Ann Arbor, and colleagues wrote in the Clinical Journal of the American Society of Nephrology.

Pruritus also appeared to be more common among those with more advanced disease. Compared with patients with stage 3 CKD, those with stage 5 had a 19% higher prevalence of moderate-to-extreme pruritus (adjusted prevalence ratio 1.19, 95% CI 0.97-1.48).

Moderate-to-extreme pruritus was also more likely to occur in CKD patients with certain comorbidities, including the following:

Lung disease: aPR 1.37 (95% CI 1.17-1.59)

Diabetes: aPR 1.17 (95% CI 1.04-1.31)

Diagnosed depression: aPR 1.29 (95% CI 1.10-1.52)

Patients who suffer from more extreme pruritus also tended to be female, and the prevalence increased with age -- i.e., pruritus was significantly more prevalent in patients ages ≥75 years versus those <55 (aPR 1.42, 95% CI 1.14-1.76).

"In dialysis facilities where 21-50% of patients reported having severe pruritus, only 1% of medical directors estimated this same prevalence," Sukul's group pointed out, citing previous research. "This may be due, in part, to underreporting by patients, as 17% of patients who were nearly always or always bothered by pruritus had not reported their symptoms to any healthcare provider."

In a statement, Sukul added: "One of the main goals of managing chronic disease is alleviating symptoms; however, this is only possible when we are aware of the suffering patients endure. This research gives us a uniquely international look at how important it is to ask our patients with chronic kidney disease if and how they are affected by pruritus."

The analysis used cross-sectional data from patients residing in the U.S., Brazil, and France from the CKD Outcomes and Practice Patterns Study. Participants completed self-reported patient surveys on health-related quality-of-life with the Kidney Disease Quality of Life Short Form and on depressive symptoms with the Center for Epidemiologic Studies Depression Scale Short Form.

Information of pruritus and severity level was gathered using a quality-of-life survey, where patients were asked how bothered they were by itchy skin within the past 4 weeks; approximately half the patients were free of pruritus, while 26% reported mild cases.

However, among the 24% with moderate-to-extreme cases, the majority said they also suffered from moderate-to-severe dry skin (73% vs 19% without pruritus). Around half of these patients also said they had restless sleep at least 3 nights per week compared with 26% of patients without pruritus.

These individuals also tended to have higher serum phosphate levels (aPR 1.07, 95% CI 1.00-1.15) and lower hemoglobin levels (aPR 0.94, 95% CI 0.90-0.98) compared with those with either mild or no pruritus. There were no differences with serum calcium levels, though. But the researchers pointed out that "given the strong correlation with advanced CKD, high serum phosphate and low hemoglobin levels may, to some extent, serve simply as markers of poor kidney function."

Self-reported depressive symptoms among patients with moderate (PR 1.83, 95% CI 1.58-2.11) or extreme (PR 2.55, 95% CI 2.07-3.13) pruritus was significantly higher compared with patients who didn't suffer from pruritus, suggesting that the condition may pose a notable threat to a patient's mental health and quality of life.

"It is conceivable that the higher prevalence of depression seen among patients with more severe pruritus could be mediated through mechanisms such as restless sleep and fatigue, which are exacerbated by severe pruritus," the group also pointed out.

Although some patients reported taking medications for their pruritus, including antihistamines, gabapentin, or pregabalin, Sukul's group suggested that future studies should aim to look at new treatment options and existing medications for pruritus.

"Some drugs have been shown to largely improve pruritus-related symptoms for a substantial percentage of patients, but even if we do not have a universally effective treatment for pruritus, recognizing that pruritus ails our patients and affects their quality of life will make them feel heard and enhance the patient-physician relationship in discussing approaches that may help provide relief from pruritus," Sukul concluded.

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